Golden Residence Senior Care

Allegation investigated: The facility allowed excluded individuals to work in the facility. Staff are forging resident documents. The Administrator is not present at the facility for a sufficient amount of time.

On 07/27/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to the facility. Upon arrival, the LPA Lee met with Administrator Tevita Kaloulasulasu and explained the purpose of the visit. The purpose of the visit was to deliver the findings related to the allegations above. At the time of the visit, the facility census was six. It was alleged that the facility allowed excluded individuals to work at the facility. This investigation consisted of interviews with Administrator Tevita Kaloulasulasu and residents, as well as a review of records and observations. On 2/17/2026, LPA Lee conducted a visit to the facility and interviewed Administrator Kaloulasulasu, who stated he has not seen excluded individuals E1 or E2 in the facility since the change of ownership in July 2025. The Administrator Kaloulasulasu also reported that, since assuming ownership of the facility, the excluded individuals have not been to the facility and that they would not permit any excluded individuals on the premises. Continued LIC 9099-C Unsubstantiated Interviews with six of six residents indicated that they had not observed the excluded individuals in the facility. LPA Lee reviewed the LIC 500 Personnel Report and the Guardian background check system and did not find either excluding individual listed. Additionally, since the change of ownership on 07/07/2025, the Department has conducted five facility visits to the facility, and during those visits, LPA Lee did not observe the excluded individuals on-site. Based on the information obtained, there is insufficient evidence to corroborate the allegation that the facility allowed excluded individuals to work in the facility. It was alleged that staff were forging resident documents. The investigation included interviews with Administrator Kaloulasulasu and residents, as well as a review of facility records. Administrator Kaloulasulasu denied the allegation, stating that the residents' LIC 602 Physician's Reports were obtained during the change of ownership and that no documents had been altered or falsified. Interviews with six out of six residents stated that facility staff transport them to medical appointments or the hospital when needed. During a facility visit on 02/17/2026, LPA Lee collected the LIC 602 Physician's Reports for all six residents. A review of the records showed that each report was complete and contained a physician's signature. On 03/09/2026, LPA Lee contacted the licensed medical professionals who completed the six LIC 602 Physician's Reports; however, they were unable to verify whether the documents had been forged or falsified. LPA Lee also attempted to verify the authenticity of the physician signatures but was unable to confirm. Based on interviews and the records reviewed, there is insufficient evidence to support the allegation that the facility forged resident documents. Therefore, the allegation is unsubstantiated. It was alleged that the facility administrator is not present at the facility for a sufficient amount of time. The investigation included interviews with Administrator Kaloulasulasu, resident interviews, a review of facility records, and observations. Administrator Kaloulasulasu denied the allegation, stating that he oversees two facilities and divides his time between them, but remains available by phone when he is not on-site. Six out of the six residents interviewed were able to identify the Administrator by name and stated that he is present at the facility. A review of the facility's LIC 500, Personnel Report, showed that Administrator Kaloulasulasu is scheduled to work at the facility on Mondays, Tuesdays, and Thursdays from 7:00 a.m. to 7:00 p.m. Additionally, since the change of ownership on 07/07/2025, the Department has conducted five facility visits (07/31/2025, 09/09/2025, 10/09/2025, 02/17/2026, and 07/01/2026), and the Administrator was present during each visit. CONTINUED LIC 9099-C Based on interviews, record review, and observations, there is insufficient evidence to support the allegation that the facility Administrator is not present at the facility for a sufficient amount of time. Therefore, the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Administrator Kaloulasulasu and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 27-AS-20260211112435

Type of visit: Required - 1 Year

On 07/01/2026, Licensing Program Analyst (LPA) Pang Lee arrived at Golden Residence Senior Care (RCFE) for the purpose of conducting a required 1-year annual inspection. LPA met with Administrator Tevita Kaloulasulasu and together conducted a tour of the home. LPA and Administrator Kaloulasulasu evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are included but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA Lee observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat was observed at 72 degrees Fahrenheit, which is within the required regulation of 68 to 85 degrees Fahrenheit. LPA Lee observed toxins located in the laundry cabinet and kept locked and inaccessible to residents. LPA Lee observed sharp knives locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. Hot water temperature was measured at 135.9 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. The bathroom grab bars were in good repair and sturdy and nonslip mats were observed on the shower floor. During today’s visit Administrator Kaloulasulasu adjusted the hot water temperature. CONTINUED LIC 809-C LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. Fire extinguisher was last serviced on 11/05/2025. The last fire drill was conducted on 06/05/2026. First aid kit was checked and is complete. LPA Lee review medications for 4 out of 6 residents by comparing the medications on hand with their Medication Administration Records (MARs) and confirmed that all records were accurate and complete. LPA Lee reviewed 6 out of 6 resident files, and they were complete. LPA Lee reviewed 3 staff files, and it was also complete. The following documents will be emailed to LPA Lee at pang.lee@dss.ca.gov by 07/08/2026 end of day 5:00 PM. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610D Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Administrator Kaloulasulasu and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Post Licensing

On 10/09/2025, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived met with administrator Tevita Kaloulasulasu and explained the purpose of the visit. Administrator assisted with today’s visit. There are currently six (6) residents living at the facility. LPA conducted a tour of the physical plant, both inside and outside, alongside Administrator Kaloulasulasu to assess any health and safety concerns. LPA inspected the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, and outdoor courtyards to ensure compliance with Title 22 regulations. The facility was observed to be clean, free of odors, and in good repair. Resident bedrooms were appropriately furnished, with adequate bedding and lighting. The hot water temperature was measured at 116.3°F. The indoor temperature was 71°F, which falls within the required range of 68°F to 85°F. LPA observed the facility maintains at least one week’s supply of nonperishable food and two days’ supply of perishable food. Additionally, a Walmart delivery consisting of 17 bags of groceries and household supplies was observed. Fresh fruit including pineapples, bananas, oranges, and both green and red apples were available on the dining table for residents. LPA also observed a designated wooden mailbox for incoming resident mail, along with a mail log tracking the date, time, and receipt of mail. The centrally stored medication area was locked and inaccessible to residents. CONTINUED LIC 809-C Fire extinguishers and first aid kits were up to date. Smoke and carbon monoxide detectors were present and in good working conditions. Required postings were displayed at the facility entrance, including: · “See Something, Say Something” poster · Ombudsmen contact information · Resident Personal Rights · Evacuation Routes · Facility License · Administrator Certificate During the visit, LPA observed Staff 1 (S1) leave a resident’s medication unattended on the kitchen counter. Administrator Kaloulasulasu immediately retrieved the medication and properly secured it. LPA reviewed files for all six (6) residents and two (2) staff members. All records were complete and contained the required documentation. Staff records confirmed that all individuals requiring caregiver background checks were fingerprint cleared and properly associated with the facility. As a result of this post-licensing the facility is in compliance with Title 22 Regulation. An exit interview was conducted with Administrator Kaloulasulasu and a copy of these LIC 809 reports along with LIC 9102 Technical Violation were provided to the facility.the state’s words, verbatim · CDSS document, Oct 9, 2025

Allegation investigated: Unlawful eviction. Facility staff withheld mail from residents.

On 09/09/25, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Bryon Toliver arrived unannounced to this facility to conduct a complaint visit. LPA me and Ombudsman with care staff Sakeasi Busele who then called administrator Tevita Kaloulasulasu. Approximately an hour later, the administrator Kaloulasulasu arrived at the facility. The purpose of this visit is to open and delivered complaint findings for the above allegations. The current census is 6. A brief interview with administrator Kaloulasulasu was conducted to go over the complaint and its findings. It was alleged that staff unlawfully evicted a resident. The investigation included interviews with facility staff, the complainant, and a review of relevant records. It was learned that Resident 1 (R1) was issued a 30-day eviction notice dated 08/11/2025; however, R1 did not receive the notice until 08/15/2025. The eviction letter cited non-payment as the reason for eviction, stating “nonpayment of the rate for basic services.” CONTINUED LIC 9099-C Substantiated However, the letter did not specify the dates for which payment was missed or provide any concrete evidence supporting the non-payment claim. LPA Lee reviewed R1’s admission agreement, which indicated that the daily rate for basic services was $202.07 per day. During an interview, Administrator Kaloulasulasu stated that R1 pays $4,500 per month, an amount inconsistent with the admission agreement’s daily rate of $202.07 per day. Additionally, the administrator was unaware of the identity of the third party covering the difference in R1’s rent. Furthermore, the eviction notice did not have several required documents, including a copy of R1’s current service plan, the relocation evaluation, a list of referral agencies, and information regarding the resident’s right to contact the department to challenge the eviction. It also omitted contact details for the local long-term care ombudsman, such as the address and telephone number. Based on the interviews and record review conducted during the investigation, LPA was able to corroborated the allegation that staff unlawfully evicted the resident. It was alleged that facility staff withheld mail from residents. The investigation included interviews with staff and residents, records review as well as direct observation. LPA Lee interviewed 4 of the 6 residents who expressed concerns about mail being withheld; all four resident stated they were not receiving their mail from facility staff. During the visit, LPA Lee observed that the printer desk drawer was filled with residents’ mail. Upon review, some of the mail belonged to former residents who had moved out prior to the change in ownership. However, it was also observed that (R1)'s mail was among the undelivered items in the drawer. Additionally, Resident 2 (R2), who moved out in mid-August 2025, had 12 unopened pieces of mail stored in the same drawer. Based on the interviews and observations conducted during the investigation, LPA Lee was able to corroborated the allegation that staff withheld mail from residents. As a result, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator Kaloulasulasu and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 27-AS-20250903212434

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Sep 26, 2025

87224(d) Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidence by: Based on record review, R1 was served an unlawful eviction notice, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: The administrator agrees to review the eviction regulations by POC date 09/26/2025. The administrator agrees to provide a written statement to LPA that states the review of eviction regulations has been completed by POC Date 09/19/2025 end of day 5:00 PM. The administrator also stated that he will revise the eviction letter and reissued it to R1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Sep 26, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities… (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications… This requirement was not met as evidence by: Based on interviews, observation and record review, residents are not given their mails, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: The administrator agrees to review the regulation cited and provide POC date 09/26/2025. The administrator agrees to provide a written statement to LPA that states the review of eviction regulations has been completed by POC Date 09/26/2025 end of day 5:00 PM. The administrator also stated that he will have a meeting with the residents in care and facility staff regarding ensuring residents’ mail are delivered to residents accordingly.

Allegation investigated: Facility alarm is disturbing residents sleep. Facility does not have hot running water for showers.

On July 31, 2025, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to initiate and conclude the investigation into the complaint allegations noted above. Upon arrival, LPA Lee met with direct care staff Ratusione Nawavoli and explained the purpose of the visit. LPA Lee requested that Ratusione contact the facility's designated administrator (FDA), Tevita Kaloulasulasu. A brief phone interview was conducted with FDA Kaloulasulasu, who arrived at the facility approximately 30 minutes later to participate in the visit. The facility census was six residents with 1 staff member present. It was alleged that facility alarm was disturbing residents’ sleep. The investigation included observations and interviews with staff and residents. During today’s facility visit, it was observed that the fire alarm in resident room #6 had been detached from the ceiling due to continuous beeping. CONTINUED LIC 9099-C Substantiated Interviews with both 2 out of 2 facility staff revealed that the fire alarm in room #6 had been beeping since July 28, 2025, typically around 2:00 AM and 4:00 AM, and continued throughout the day. Staff confirmed that the alarm was removed by a resident in room #6 from the ceiling because of the nonstop beeping. Facility Designated Administrator (FDA) Tevita Kaloulasulasu acknowledged that staff informed him of the issue on the same day it began (07/28/2025). He stated that he visited the facility, observed the alarm, and heard it beeping, but had not yet resolved the problem. FDA Kaloulasulasu indicated that a maintenance worker is scheduled to come to the facility today to address the issue. Additionally, interviews with 4 out of 4 residents confirmed that the fire alarm beeps regularly throughout the day and that residents are not able to sleep because staff have not resolved the problem. This was found to be out of compliance with Title 22, Regulation 87468.1(a)(3) Personal Rights of Residents in All Facilities. The facility was not observed to be free from interference with residents' daily living functions, such as sleeping. Based on observations and statements gathered during the investigation, the LPA was able to corroborate the allegation. It was alleged that the facility does not have hot running water for showers. The investigation included observations and interviews with staff and residents. During today’s facility visit, LPA Lee, along with direct care staff Ratusione Nawavoli, tested the hot water in resident bathroom #1, located on the right side of the facility. The hot water was found to be functional and measured at 118.0°F. However, during interviews, 2 out of 2 facility staff admitted that the hot water had not been working prior to LPA Lee’s visit. Staff member S1 stated that approximately three weeks ago, the hot water in shower #1 (on the right side of the facility) was not functioning. Despite attempts to adjust the shower knob, only cold water was dispensed. As a result, S1 redirected residents to use shower #2, located on the left side of the facility, which is typically designated for staff use. S1 reported the issue to FDA Kaloulasulasu. In an interview with FDA Kaloulasulasu, it was confirmed that he had been informed of the problem by S1 but did not personally check the shower to verify whether it was working or dispensing hot water. This was found to be out of compliance with Title 22, Regulation 87303(e)(2) Maintenance and Operation. Facility faucets used by residents for personal care, such as showering, shall deliver hot water. Based on observations and statements gathered during the investigation, LPA was able to corroborate the allegation. Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with direct care staff Ratusione and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Jul 31, 2025 · control 27-AS-20250730162729

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 7, 2025

87468.1(a)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This was not met as evidenced by: Based on observations and interviews with facility staff and residents in care, the facility did not ensure staff that the fire alarm in resident’s room was in good repair which kept beeping and causing resident to not be able to sleep. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: During today’s visit, administrator Tevita Kaloulasulasu had the facility maintenance guy replace the fire alarm battery to fix the beeping and re-atached the fire alarm back on the ceiling. The Administrator agreed to conduct training for all staff on residents’ personal rights in all facilities. Additionally, the Administrator will review the cited regulation and submit a signed letter of acknowledgment to LPA Lee confirming that the regulation has been read and understood. The Administrator will also provide LPA Lee with the following by the Plan of Correction (POC) due date of August 7, 2025, by 5:00 PM: Proof of the training conducted, training materials used and staff sign-in sheet

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 7, 2025

87303(e)(2) Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water... This was not met as evidenced by: Based on observations and interviews with facility staff and residents in care, the facility did not ensure that the shower in the resident bathroom is delivering hot water for showers. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: During today’s visit, direct care staff Ratusione Nawavoli was able to adjust the shower knob and restore hot water in the shower. The Administrator agreed to conduct training in Maintenance and operation. Additionally, the Administrator will review the cited regulation and submit a signed letter of acknowledgment to LPA Lee confirming that the regulation has been read and understood. The Administrator will also provide LPA Lee with the following by the Plan of Correction (POC) due date of August 7, 2025, by 5:00 PM: Proof of the training conducted, training materials used and staff sign-in sheet. The administrator will also conduct a hot water temperature check in the resident shower and provide LPA Lee with the shower log by POC date as well.

Type of visit: Prelicensing

On 07/03/2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility and met with the applicant Tevita Kaloulasulasu and licensee Julie Nonu. The purpose of today's visit is to conduct a follow-up inspection related to the Pre-Licensing visit that took place on 07/01/2025. During that initial visit, several items were identified as needing correction to bring the facility into compliance in order to proceed with the licensing process for a Change of Ownership. According to applicant Tevita, the facility will have a live-in staff and will continue to provide 24-hour care, seven days a week. The following deficiencies observed during the previous visit have been corrected: · An updated facility interior sketch accurately reflected staff and resident rooms, as required by the approved fire clearance, was submitted via email to LPA Lee on 07/03/2025. · The closet door in Bedroom #7 was observed to be in good repair. · Closet doors in Bedrooms #1 and #3 were observed to have knobs installed, allowing for easy use by residents. · Review of personnel records showed that S1’s LIC 501 has been completed and is now up to date. · Records confirm that S2’s LIC 501 has been completed. Additionally, the Health Screening and TB test were completed on 07/01/2025. Continued LIC 809-C During today’s visit, LPA Lee reminded the applicant that any changes to the interior or exterior of the facility must be pre-approved by both the Department and the Fire Department. LPA Lee also introduced the Technical Support Program (TSP) to the applicant, Tevita, who expressed interest in participating in the program. LPA Lee informed the applicant that a referral to TSP will be completed once applicant is licensed. The applicant has successfully passed the pre-licensing component of the application process. Component III was also reviewed and completed with the applicant. LPA will notify the Centralized Applications Bureau (CAB) that the pre-licensing has been completed and approved. An exit interview was conducted, and a copy of this report was provided to the applicant Tevita.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Prelicensing

On July 1, 2025, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct a Pre-Licensing visit following a change of ownership. Upon arrival, LPA was greeted by the applicant, Tevi Kaloulasulasu, who will also serve as the facility administrator. LPA Lee was also met later during the visit by the Licensee, Julie Nonu. LPA explained the purpose of the visit and proceeded with a brief interview with the applicant Tevi and Licensee Julie. The census is five. The facility has a fire clearance for 6 non-ambulatory residents only. At this time, the facility is not approved to accept or retain any residents who are bedridden, nor does it have an approved hospice waiver. LPA conducted a tour of the facility, inspecting both the interior and exterior. Common living spaces, resident bedrooms, bathrooms, the kitchen, and other areas intended for resident use were all toured. It was noted that the furniture and furnishings were adequate and in good condition to meet the needs of the residents at this time. The laundry room was also inspected, and LPA observed that laundry detergent, bleach, and other cleaning supplies were safely stored and inaccessible to residents. All required postings were visible throughout the facility. Smoke and carbon monoxide detectors were tested and found to be in good working condition. A fire extinguisher, located in the family room, was observed to be serviced and valid until 11/27/2025. LPA toured all five resident bedrooms, as well as one caregiver room. All furniture and furnishings appeared to be in good repair; however, LPA Lee observed that the bi-fold closet doors in Bedrooms #1 and #3 require knobs to allow residents to open them properly. Additionally, the closet doors in Bedrooms #4, #5, and #7 were found to be in despair and difficult to open. Continued LIC 809-C During today’s visit, the facility’s maintenance staff was able to repair the closet doors in Bedrooms #4 and #5. During the bathroom inspections, hot water temperatures were taken and the hot water temperature measured 106.3 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. In the kitchen, LPA observed an adequate supply of food at least two days’ worth of perishable and seven days’ worth of non-perishable items sufficient to meet the residents’ needs. Kitchen knives were securely locked and inaccessible to residents. The facility’s internal temperature was observed to be 71 degrees, and a public telephone was available in the kitchen for residents’ use. The linen closet, located in the hallway, contained sufficient supplies of clean towels, blankets, and bed linens. Medications were stored in a locked centralized cabinet located in the laundry. Together with the applicant, the resident’s medications with the medication logs were reviewed, which were found to be complete and accurate. File reviews were conducted for five residents and two staff members. 1 out of 5 resident files were incomplete. Resident 1 (R#1)’s LIC 601 Identification and Emergency Information was incomplete and signed. R1’s LIC 603A Resident Appraisal is also incomplete but signed by the administrator Julie Nonu and has no resident signature. LPA reviewed two staff files, and they were incomplete. Staff #1 (S1) LIC 501 is incomplete. S2’s LIC 501 Personnel Record is also incomplete. S2 is also missing LIC 503 Health Screen and TB. The First Aid Kit was present and contained the required items. Outside the facility, the physical plant was in good repair, free from hazards. The perimeter fencing was secure, and all gates were in working condition. During today’s visit, LPA Lee observed that the interior layout of the facility does not align with the submitted and approved facility sketch. According to the approved sketch, bedroom #7 is designated for one non-ambulatory resident, and bedroom #5 is designated as a staff room. However, during the inspection, it was observed that: · Bedroom #7 is currently being used as a staff room · Bedroom #5 is also being used for residents Continued LIC 809-C Although a revised facility sketch was submitted to the Central Applications Bureau (CAB), it inaccurately indicates that Bedrooms #5 and #6 are designated as staff rooms. The following corrections must be made prior to licensure: · Submit an updated facility sketch that accurately reflects staff and resident room per the approved fire clearance · Repair the closet door in Bedroom #7 to ensure it is in good condition · Install knobs on the closet doors in Bedrooms #1 and #3 to allow residents to open them easily · S1 LIC 501 Personnel Record needs to be completed. · S2 LIC 501 Personnel Record needs to be completed and needs LIC 503 Health Screen and TB prior to working at the facility. During today's visit LPA Lee informed Licensee Julie Nonu that S2 can't be in the facility providing care without a health screening and TB test. LPA Lee discussed and recommended the Technical Support Program (TSP) to the applicant, Tevi. The applicant expressed interest in being referred to the program. LPA Lee advised that the referral to TSP will be completed once the applicant is officially licensed. Based on the observations made during the visit, the applicant has not passed the Pre-Licensing component. LPA will notify CAB that the Pre-Licensing visit was not approved. An exit interview was conducted, and a copy of the report was provided to the applicant Tevi.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 Method: Telephone call with CAB COMP II Participants: Kaloulasulasu, Tevita On 6/27/2025, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 27, 2025